Motivational Interventions in Prenatal Clinics

Although the risks associated with pregnancy are well-documented, prevention efforts, for the most part, have not reached women who drink at levels that present the greatest risk. Recent clinical studies and demonstration projects show that interventions by obstetric caregivers can help reduce drinking even among women who consume alcohol at the heaviest levels. Brief interventions and motivational interviewing are two approaches that can be adapted for busy medical offices to provide interventions before, during, and after pregnancies. By combining these interventions with a stepped-care approach, practitioners will be able to intervene to prevent drinking during pregnancy while minimizing costs to the patient and demands for limited clinic resources.

T he risks associated with drink ing during pregnancy are well documented, as evidenced by the other articles in this issue of Alcohol Research & Health. Television and radio public service messages, warning labels, and educational campaigns aimed at informing the public about the harm caused by fetal alcohol exposure have led many women to quit or reduce their drinking before or during pregnancy (Waterson and Murray-Lyon 1990). These universal prevention efforts, however, have been largely ineffective in reaching women who drink at levels that present the greatest risks for damaging the fetus (Hankin 1994;Stratton et al. 1996). Community-wide and multi-level strategies for reaching women who drink at the heaviest levels are needed to reduce the incidence of Fetal Alcohol Syndrome and other alcohol-related neurodevelopmental disorders (Smith and Coles 1991). One approach that shows promise for reaching women at risk is the integration of alcohol coun seling into gynecologic and obstetric care. Intervening as part of gynecologic and obstetric care enables health care practitioners to reach women before they conceive, during pregnancy, and as part of postpartum care. Such intervention is especially important for pregnant women who would not consider alco hol treatment, but by virtue of their drinking habits (e.g., weekend "binges") would be placing their unborn babies at risk for alcohol-related impairment.
Several clinical studies and demon stration projects have shown that women can be successfully engaged in efforts to decrease their drinking when approached during routine obstetric care. Moreover, follow-up evaluations of babies born to mothers who reduced their drinking during their pregnancies have revealed better infant outcomes. Based on our review of the effectiveness of interven tions held in prenatal clinics, this article presents information on adapting brief motivational approaches for alcohol interventions during prenatal health care and provides a specific model for intervening.

Methodology
To review the effectiveness of alcohol interventions held in prenatal clinics, we selected 22 studies according to the NANCY SHEEHY HANDMAKER, PH.D., is a research assistant professor and princi pal investigator of a National Institute on Alcohol Abuse and Alcoholism-funded project, "Motivating Pregnant Drinkers" and PAULA WILBOURNE, M.S., is a doctoral student in the Department of Psychology, University of New Mexico, Albuquerque, New Mexico.
following criteria. The intervention had to be conducted in a prenatal care set ting or in conjunction with a prenatal care intervention. The study had to include a clear measurement of drinking. In addi tion, the study had to consider a variety of outcome variables to determine the effectiveness of the treatment in reduc ing alcohol-related harm: alcohol use, treatment retention, pregnancy outcome, and infant outcome. Randomized controlled trials, demonstration pro jects with some comparison data, and demonstration projects without com parison data were included. We excluded studies that measured abstinence from all substance use as the only outcome variable or that dealt with "alcoholism," but did not measure alcohol use. Demon stration projects without comparison data which did not demonstrate that a significant proportion of participants were drinking also were excluded, because the conclusions about the effect of the treatment on drinking were too tenu ous to be interpreted. (For specific information on the studies examined here, see sidebar.)

Intervening During Obstetric Care
Despite the evidence that women will engage in alcohol counseling when it is offered as part of their prenatal care, few obstetric practitioners routinely screen, assess, and counsel patients about prob lem drinking (Morse and Hutchins 2000). The reasons obstetricians frequently cite for not intervening include their lack of time, training, and resources, as well as resistance by the patients themselves. However, as discussed below, brief interventions and motivational interviewing are two methods that address health care practitioners' concerns and show promise for overcoming these obstacles to intervening.

Brief Interventions
Routine screening is an essential step toward identifying drinking among pregnant women (Morse and Hutchins 2000). Once a woman is identified as a drinker, health care practitioners are faced with the challenge of how to intervene appropriately. Brief alcohol counselingthat is, one to three patient consultations held in primary health care settings with personalized feedback on health problems and risks, advice, and options for treatment and self-helphave consistently shown significant reductions in problem drinking when compared to no counseling (Bien et al. 1993;Miller 2000). Other benefits of brief alcohol interventions as part of health care have been improvements in alcoholrelated health problems (e.g. liver dis ease), decreased morbidity, and increased adherence to alcohol treatment (Bien et al. 1993). Somewhat surprisingly, brief interventions consistently show outcomes for problem drinking similar to more extended treatment and these changes can be relatively enduring, lasting up to a year or longer (Bien et al. 1993;Miller 2000).
Recent studies of brief interventions have demonstrated their feasibility for reducing alcohol consumption among pregnant drinkers. Hankin and colleagues (2000a) conducted a randomized controlled trial to examine the effect of two brief intervention strategies on drinking in subsequent pregnancies. Women who reported drinking during pregnancy were randomly assigned to receive either the brief intensive intervention or a control condition of a standard warn ing about antenatal drinking. The con trol group intervention was described as using encouraging statements such as, "You can have a healthier baby if you cut back or stop drinking during preg nancy." Participants then were followed into their subsequent pregnancies. The group that received the intensive inter vention was offered brief "booster" ses sions during the subsequent pregnancy. Although the intensive brief intervention group was drinking about the same amount in the second pregnancy as the first pregnancy, women in the control group were drinking almost twice as much as they consumed during the first pregnancy. Thus, the benefits of the brief, but intensive intervention apparently dampened the rise in potential fetal alcohol exposure levels during subse quent pregnancies. Furthermore, the study found that women who reported the heaviest prepregnancy drinking showed the largest reduction in drink ing following the brief intensive inter vention. More importantly, the study found that babies born to women in the brief intensive intervention groups showed better growth outcomes at birth (Hankin 2000b). Chang and colleagues (2000) inves tigated whether adding a brief inter vention to standard care would increase abstinence rates among a sample of pregnant outpatients. The intervention focused on setting drinking limits and problem-solving about how to avoid drinking in risky situations. Most patients who set abstinence as their drinking goal at the beginning of their prenatal care either remained abstinent or sig nificantly reduced their alcohol con sumption. This outcome was positively correlated to the patients' concerns about the effect of drinking on their babies. Women who reported that their reason for change was apprehension about the effects of fetal alcohol exposure drank significantly less at followup than the other participants.

Motivational Interviewing
In the absence of extensive alcohol treatment, an explanation for the suc cess of brief interventions is that they increase the patient's readiness for change. Motivational interviewing is an empathic patient-centered counseling approach for increasing readiness by resolving ambivalence about behavior change (Miller and Rollnick 1991). The pro cess involves the exploration of the patient's ambivalence (i.e., the "pros" and "cons" for drinking) in an atmo sphere of acceptance, warmth, and regard. Although the session is directive, direct persuasion and coercion are avoided. A goal is to enhance the dis crepancy between the reasons for chang ing (e.g., risks of brain damage to the fetus) versus staying the same (e.g., not giving up drinking friends). Important qualities of an effective interviewer are maintaining an optimistic attitude about change, having a compassionate style, and avoiding arguments or evok ing patient defensiveness (Miller and Rollnick 1991).
More than 24 studies of motivational interviewing have yielded beneficial effects in decreasing problem drinking, drug addiction, marijuana abuse, diabetes management, smoking, and cardiovas cular rehabilitation (Miller 2000). Many studies have used motivational interviewing as a stand-alone intervention rather than as an addition to more extensive clinical treatment. The specific format of motivational interviewing has varied in length from a single coun seling session, and a two-session assess ment and feedback approach, to the four-session Motivation Enhancement Therapy (Project MATCH 1997). Clinical studies show that motivational interviewing has been as effective in reducing drinking and related problems as more extensive alcohol treatments such as Cognitive-Behavioral Therapy and 12-Step Facilitation, and consis tently yields beneficial and relatively lasting effects (Project MATCH 1997).
Health care practitioners are likely to see women who are ambivalent about abstinence. Those women often either are unaware that their level of alcohol consumption presents a risk to the fetus, or they recognize that drinking is a problem but have not committed to abstinence. Offering premature advice or making referrals to alcohol treatment is likely to be ineffective, creating instead a defensiveness among women who are undecided about whether the costs of drinking outweigh the perceived bene fits, or who are uncertain about whether they can change (Miller and Rollnick 1991). Researchers have found that when interviewers exert more pressure or present intellectual arguments, clients tend to react more defensively. The degree of defensiveness or resistance that a patient exhibits during a session has been shown to be a predictor of poorer drinking outcomes, and researchers have found that an empathic therapist style was predictive of decreased patient resistance .
Several National Institute on Alcohol Abuse and Alcoholism-funded research programs are underway to evaluate the benefits of motivational interviewing with pregnant problem drinkers. One study has reported findings on a pilot study of these methods for pregnant drinkers (Handmaker et al. 1999b). Following completion of a screening questionnaire, pregnant women who reported any recent alcohol consump tion were randomly assigned to either a motivational interview or an informa tion-based intervention. The informa tion-based intervention was a personal ized letter cautioning that drinking was known to be hazardous and recom mending that the participants talk about this with their obstetric care practitioners. The goal of the motiva tional interviewing session was to facili tate a decision to change by gently guid ing the participants to weigh their drinking against the risks. A key strat egy toward facilitating a decision to abstain was exploring and resolving the participants' ambivalence about decreasing their drinking. The health of the unborn baby was a major moti vational theme, although direct assess ment of the impact of drinking on the baby's health was not available. Instead, a gestational chart illustrating fetal development at critical periods was incorporated into the motivational interviewing session. The interview proceeded with open-ended questions (e.g., "What do you know about the effects of drinking during pregnancy?") to evoke concerns related to the risks associated with fetal alcohol exposure and empathic reflections of the partici pant's responses (e.g., "You want your baby to have the best chance at life") to reinforce talk about change. As in Chang's study, counselors helped the women explore alternatives to drinking, espe cially for high-risk situations (e.g., not drinking at a party) and helped them generate their own ideas about main taining abstinence, including engaging in alcohol treatment. Results showed both the treatment (i.e., motivational interview) and control (i.e., caution plus referrals) groups significantly decreased their alcohol consumption at the fol lowup. The study found a differential response, however, to the motivational interview in women drinking to high doses, as estimated by peak blood alco hol concentration (BAC) 1 . Women who had been reaching high BACs before the motivational interview were drink ing at significantly lower levels at fol lowup compared to women in the con trol group. That is, the women in the treatment group either were extending their alcohol consumption over longer periods or they consumed less alcohol during a drinking episode. Thus, women who were placing their unborn babies at the greatest risk, based on estimated doses of alcohol exposure, responded favorably to the motivational interven tion. These findings are preliminary. Moreover, the use of average metabolism rates to calculate measures of BACs is not exact because of individual differ ences in metabolism rates. However, the outcomes found among the heavi est drinkers are consistent with the lit erature on motivational interventions (Hankin et al. 2000a;Miller 2000).
An interesting finding from the pilot study of motivational interviewing seen in other studies of brief interven tions is that the assessment process itself may lead to a reduction in drink ing. It is plausible that assessment meth ods conducted in a reflective, nonjudg mental interviewing style may increase awareness and problem recognition, processes known to promote behavior change. This potential effect of screen ing and assessment among female par ticipants has been replicated in other studies (e.g., Scott and Anderson 1990).

Comprehensive Care
Reviews of treatment programs for pregnant women who use alcohol or drugs suggest that comprehensive care which coordinates medical with alcohol and drug treatment and social services is most effective (Finkelstein 1993). This is particularly true for women who drink at the heaviest levels, who are likely to be smoking or using illicit drugs, to be socioeconomically disad vantaged, or to have comorbid depres sion or other psychological distress.

Methods Used in Selecting Studies
The studies reviewed here include a wide range of treat ment approaches, screening and recruitment criteria, gestational periods, settings, outcome variables, and followup periods (see table). Researchers recruited most of the study participants when they were receiving prenatal care from either hospital-based programs or maternal health clinics. Participants were generally selected based on alcohol use. Investigators also selected women who drank at moderate to excessive levels as well as women who currently were experiencing alcoholrelated problems. In some instances, treatments were compared in general obstetric populations or in women at risk for reasons other than drinking (e.g., women who smoked or were unmarried). Most of the recruited women were not enrolled in formal alcoholism treatment, although four studies reported on women who were participating in a combined obstetric and substance abuse treatment program.
Thirteen of the studies provided a description of a single treatment intervention and included data describing the outcome of women who participated in the project. Studies of that design are described here as demonstration projects. Two of these reported comparative data of women who refused treatment with women who attended treat ment (Eisen et al. 2000;Whiteside-Mansell et al. 1999). Another study of women who were enrolled in a single treatment program compared those who had comorbid conditions with those who did not (Brems and Namyniuk 1999). Interventions in the demonstration projects typi cally were described in general terms (e.g., counseling, education, substance abuse treatment, or disease model education) or by referring to a specific treatment format (e.g., day treatment, residential treatment, or home visits).

Demonstration Projects
Demonstration projects have made major contributions to the study of drinking during pregnancy and its pre vention. These projects have shown that women in prenatal care settings can be screened and recruited for treatment by their health care providers and that women often reduce their drinking during pregnancy (e.g., Little et al. 1985;Meberg et al. 1986;Higgins et al. 1995). The demonstration projects also show that offspring of women who reduce their drinking have a lower incidence of fetal alcohol effects than women who continue drink ing throughout their pregnancy (Little et al. 1984).
In gathering this body of research, the investigators were creative in the methods they used to recruit women, were flexible in the times during gestation that women were treated, and were thorough in the diverse ways in which they measured outcomes. Additionally, demonstration projects measured the variability of women who partici pated in treatment and their drinking-related outcomes (i.e., younger women may cut back their alcohol use more than older women) (Rosett et al. 1978). ecause of the design limitations (i.e., the lack of control groups), however, these demonstration projects do not allow clear conclusions regarding the efficacy of the treatments used.

Controlled Trials
The main weaknesses of the literature on alcohol treat ment within prenatal services are the lack of control groups in the majority of reports and the small number of well-controlled trials. Significant proportions of women in the demonstration projects decreased their drinking, but the outcomes cannot be attributed directly to the treatments. Because many women decrease or quit drinking on their own during pregnancy (Kaskutas and Graves 1994), the absence of comparison groups in most of these studies makes it difficult to discern the efficacy of the treatments. In addition, the high dropout rates and the low numbers of women drinking at the heaviest levels in some of these studies render the find ings unconvincing as prevention strategies.
Nine of the studies used methods to equate the groups (i.e., random assignment and cohort design), thereby allowing stronger inferences to be made regarding the efficacy of the treatments tested. In this group of studies, alcohol interventions ranged from brief education, advice, and self-help manuals to more intensive programs, includ ing general alcohol counseling with case management or supportive counseling. One such investigation found no added benefit to supplementing standard care with a telecommunications network that provided supportive telephone messages, a patient information hotline, peer conference calls, and telephone followups (Alemi et al. 1996). Waterson and Murray-Lyon (1990) found that women who received advice or who received both advice and a video in addition to the written materials did not report drinking any less than those who only received written materials. This finding may indicate that the written materials alone were enough to catalyze change (Waterson and Murray-Lyon 1990).
Other controlled trials found differences between the interventions used. Positive comparisons indicated the benefit of reduced drinking from 10-minute education sessions combined with self-help; one to two home visits; brief interventions; and a motivational intervention, each B 222 Alcohol Research & Health of which was provided separately in several different samples (Reynolds et al. 1995;Olds et al. 1997;Hankin et al. 2000;Handmaker et al. 1999). Surprisingly, one investigation on the use of support ive counseling found that more drinking occurred in the intervention group (Meberg et al. 1986). The higher rates of drinking in the intervention group may have been related to pretreatment differences in drinking between groups that were not controlled and the retrospective assessment of the control group who may have underreported their drinking. In all cases, the interventions demonstrating positive effects on drinking outcome in the prenatal setting occurred outside of a formal treat ment program. Furthermore, the interventions were short term, ranging from 10 minutes to two visits.

Gender and Other Population Differences in Treatment
The small number of well-controlled trials reporting on the treatment of alcohol problems in women and pregnant women requires us to interpret the findings of this review with caution. Many treatments have been tested both in male and primarily male samples, but important epidemiological issues distinguish female problem drinkers from male problem drinkers. Differences also exist between pregnant drinkers and women who seek treatment when they are not pregnant.
Distinctions in alcohol use between men and women include what qualifies as safe drinking levels, the preva lence of alcohol problems, and the pattern of heritability (National Institute on Alcohol Abuse and Alcoholism 2000). Differences also can be found among women who seek alcohol treatment. In general, pregnant drinkers who seek treatment tend to be younger and experience fewer alcohol-related problems than women who seek treatment when they are not pregnant (McClelland 1985). The differences between these two populations may necessitate different treatments for women who are preg nant versus those who are not. However, the results of the studies reviewed here appear consistent with the broader treatment literature, which shows that brief interventions and motivational interventions have strong track records for reducing alcohol consumption by both problem drinkers and dependent drinkers (Miller et al. 1998).
Some aspects to treating women who are pregnant are unique to this population, however. Dvorchak and col leagues (1995) cited transportation problems, limited financial resources, and lack of available child care as bar riers to treatment among pregnant women. Additionally, Simons and colleagues (2000) stress the importance of addressing the issue of domestic violence and related trauma when counseling women about substance abuse. Although these observations may seem intuitive, no com parisons using an experimental design have been made between treatments addressing these issues and treat ments focusing only on drinking. The disparity between speculative theories about treating pregnant women and actual findings clearly indicates that more work is needed to test the ideas that have been proposed in the literature.  Comprehensive care programs vary in treatment modalities and services, but components such as group or individual therapy, detoxification, case manage ment, parenting classes, and self-help frequently are included. In the absence of clinical trials comparing comprehensive care with the alternative, less-intensive approaches, such as brief interventions and motivational interviewing, researchers cannot determine which patients need comprehensive care and which compo nents of care are essential. In the next section, we propose a stepped approach to intervening should a patient need more than a motivational interview or brief intervention.

A Stepped Care Model for Prenatal Settings
A "one-stop shopping" concept in which social workers, psychiatrists, case man agers, and psychotherapists work col laboratively as part of a multidisciplinary team within obstetric care is the ideal when caring for the addicted pregnant patient (Tanney and Lowenstein 1997;Finkelstein 1993). However, most prenatal programs (e.g., private practices, rural health care, and stand-alone outpatient obstetric clinics) are not prepared to offer such comprehensive and integrated care. A feasible alternative is the provision of brief interventions, refer rals for other services, and monitoring, which can lead to reductions in drinking among pregnant women as well as to increases in adherence of referrals to alcohol and drug treatment and other support services.
A recent approach to decisionmak ing about alcohol treatment known as "stepped care" applies decision rules derived from other areas of health care to the alcohol treatment field (Sobell and Sobell 2000). According to this approach, alcohol treatment that is individualized, consistent with state-ofthe-art literature, and the least restric tive, is likely to work. This approach emphasizes "serving the needs of clients efficiently, but without sacrificing the quality of care" (Sobell and Sobell 2000, p. 578). Stepped care is consistent with health care delivery for other health problems and minimizes costs and demands for limited resources. Used within a network of comprehensive services, stepped care also reduces the demands on female patients for child care, transportation, and expenses for healthcare, which women frequently mention as obstacles to treatment.
Stepped care begins with broad, sen sitive screening that includes brief selfadministered questionnaires like the five-item TWEAK, which has demon strated sensitivity and specificity for problem drinking among pregnant women (Stratton et al. 1996). A model for intervening with the pregnant substance-using woman is illustrated in the figure below. This model proposes the use of broad, sensitive screening in prenatal clinics and, for those who report either drinking during pregnancy or alcohol-related problems in the past year, a more thorough assessment interview conducted in an empathic style. The next step may be a second assess ment, combined with advice. This step may suffice for lighter drinkers and also would identify the heavier, high-risk drinkers who need brief intervention and monitoring. The third step is a motivational intervention with a health care professional, during which the patient and counselor might negotiate a plan for change. Plans for change can be any combination of options that will support sobriety, such as special ized alcohol treatment, self-help, com munity resources, case management, and financial assistance.
Heavy drinking also is likely to be accompanied by comorbid conditions of depression, anxiety, and other psychological problems as well as concomitant drug use, particularly cigarette smok ing. High rates of posttraumatic stress disorder and histories of sexual abuse frequently are reported in female substance-abusing populations. As a result, matching patients with treatment to meet specific needs, such as mental health care with a substance use component, is recommended. Family histories of drinking among female relatives and drinking among significant others have been correlated with problematic drink ing (e.g., Handmaker et al. 1999b; Stratton et al. 1996). Consequently, strategies that include family members are likely to improve outcomes. Ideally the prenatal care setting would develop a network with other services for referral as well as monitor progress and make new referrals if previous actions were not helpful in reducing harm.

Future Directions
Most medical schools and continuing medical education courses offer minimal training, if any, in alcohol counseling. Health care practitioners need practical strategies for brief patient consultations that will foster compliance with absti nence and encourage participation in alcohol treatment when necessary. A feasibility study of the use of videotaped instruction as a method for improving the efficacy of brief counseling among health care practitioners demonstrated one possible strategy (Handmaker et al. 1999a). In that study, health care prac titioners were randomly assigned to view either a videotaped training based on motivational interviewing or a docudrama about the effects of fetal alcohol syndrome. Results showed that the practitioners who viewed the docu drama demonstrated a more confront ational style in role-played sessions follow ing the video than those who viewed the skills-training videotape. Although the health care practitioners who viewed the counseling training tape were not proficient in motivational interviewing skills after one session, they appeared to direct the consultation more effectively toward a decision to change. These health care practitioners demonstrated a nar row set of skills shown in the videotape that included developing a discrepancy between reasons for change and not changing, being empathic, supporting the belief in the patient's ability to change, and minimizing confrontation. Ongoing booster sessions or guided experiences in addition to videotaped training might lead to increased proficiency.

Conclusions
Most studies of integrated alcohol treat ment with prenatal care have been limited by the lack of control groups, small numbers of heavy drinkers, and inability to separate the effects of treatment from naturally occurring change during preg nancy. Another limitation is the general lack of confidence in the outcome measures, which rely primarily on self-report.
Demonstration projects have shown that women can be screened for their drinking by their providers in prenatal care settings. Controlled trials found that even brief interventions produce positive results. Brief interventions and A stepped-care model for intervening with pregnant women who are using alcohol or other drugs. Obstetric examination motivational interviewing are two ways obstetric care providers can intervene with pregnant women who continue to drink. Both these methods may be applied through a stepped care approach that can serve the needs of clients effi ciently without sacrificing quality of care. By applying decision rules derived from other areas of health care, practi tioners can minimize costs and demands for limited resources.
Researchers have recommended embedding alcohol and drug use within the context of broader efforts toward health and well-being. Continuing to educate the public about how to inter vene with family members and using media campaigns to encourage women to discuss alcohol use in health care set tings may be particularly advantageous.
Family counseling, which has been shown empirically to increase engagement and retention of resistant problem drinkers and drug users (Smith et al. 1999), is a yet untested direction for treatment of pregnant populations. Further study is also necessary to learn the best treatment for female problem drinkers and to dis cern any differences between pregnant women and those who seek treatment when they are not pregnant. In addi tion, further study of methods to increase the effectiveness of health care practi tioners in brief interventions and moti vational interviewing is needed. s